This submission proposes to develop a multi-disciplinary Developmental Center for Evaluation and Research in Patient Safety (DCERPS) which will apply systems engineering, human factors engineering, and industrial engineering safety approaches to research on patient safety, health care worker safety, and medical errors reduction, incorporating a holistic organization construct which applies to all patients and medical providers across the spectrum of patient populations and healthcare settings. The DCERPS on System Engineering will formalize and further develop an existing collaboration of medical and engineering expertise, and seek input from medical consumer groups and other interested collaboration of medical and engineering expertise, and seek input from medical consumer groups and other interested parties, to conduct patient safety research across a spectrum of patient populations and patient care settings. Experts in human factors, systems engineering, and quality engineering will join experts in epidemiology, pharmacology, acute care medicine, primary care medicine, quality improvement in healthcare, long-term care, risk analysis, and medical informatics to empirically examine systems design, quality management, job design, and technology implementations that affect patient safety issues. Because systems and human factors engineering uses the entire system as the context for analysis, and includes the analysis of process of process as well as content, research results will be widely generalizable across multiple patient populations and healthcare settings. The DCERPS on System Engineering will draw on its current expertise, scientific literature, and future research findings to develop educational programming on patient safety issues for internal use in developing a coherent research team, and for medical consumers, medical providers, and the research community. Existing ties to medical delivery systems (St. Mary's Hospital, Meriter Hospital, UW-Hospitals and Clinics, William S. Middleton Veterans Administration Hospital, Dean Health System, state-wide family practice clinics, national network of long-term facilities) will be expanded and formally defined. A planning director, planning committee, multi- disciplinary research team, and external advisory board have been assembled and will engage in a strategic planning process utilizing Breakthrough Thinking TM principles and techniques to accomplish these ends and ultimately develop a research proposal for a pilot study based on one or more of the four research subject areas defined by AHRQ.